OB Exam 2 Practice Questions
A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? 1.Place the client in Trendelenburg's position 2.Call the delivery room to notify the staff that the client will be transported immediately 3.Gently push the cord into the vagina 4.Find the closest telephone and stat page the physician
1.Place the client in Trendelenburg's position
During labor, progressive fetal descent occurs. Place the stations listed in their proper sequence from first to last. All options must be used 1. 2+ station 2. -4 station 3. -2 station 4. 0 station 5. +4 station
2. -4 station 3. -2 station 4. 0 station 1. 2+ station 5. +4 station
A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction? 1.Early decelerations 2.Variability 3.Accelerations 4.Variable decelerations
4. Variable decelerations
A nurse educator in the labor and delivery unit is reviewing the use of chemical agents to promote cervical ripening with a group of newly hired nurses .Which of the following statements by a nurse indicates understanding of the teaching? A: "They are administered in an oral form." B: "They act by absorbing fluid from tissues." C: "They promote dilation of the os." D: "They include an amniotomy."
A: "They are administered in an oral form."
The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? A: Administer oxygen via face mask B: Place the mother in a supine position C: Increase the rate of the oxytocin intravenous infusion D: Document the findings and continue to monitor the fetal patterns
A: Administer oxygen via face mask
The nurse is monitoring a client who is in active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed her at risk for this complication? Select all that apply. A: Age 54 B: Body mass index of 28 C: Previous difficulty with fertility D: Administration of oxytocin for induction E: Potassium level of 3.6
A: Age 54 B: Body mass index of 28 C: Previous difficulty with fertility
The nurse is measuring a contraction from the beginning of the increment to the end of the decrement for the same contraction. The nurse would document this as which finding? A: Duration B: Intensity C: Frequency D: Peak
A: Duration
A nurse is caring for a patient who has been in labor for 12 hr, and her membranes are intact. The provider has decided to perform an amniotomy in an effort to facilitate the progress of labor. The nurse performs a vaginal exam to ensure which of the following prior to the performance of the amniotomy? A: Fetal engagement B: Fetal lie C: Fetal attitude D: Fetal position
A: Fetal engagement
The nurse notes that the fetal head is at the vaginal opening and does not regress between contractions. The nurse interprets this finding as which process? A: crowning B: descent C: engagement D: restitution
A: crowning
A nurse is teaching a client about the benefits of internal fetal heart monitoring. Which of the following statements should the nurse include in the teaching? (Select all that apply) A: "It is considered a noninvasive procedure" B: "It can detect abnormal fetal heart tones early" C: "It can determine the amount of amniotic fluid you have" D: "It allows for accurate readings with maternal movement" E: "It can measure uterine contraction intensity"
B: "It can detect abnormal fetal heart tones early" D: "It allows for accurate readings with maternal movement" E: "It can measure uterine contraction intensity"
A pregnant woman at 32 weeks gestation calls the clinic and informs the nurse that she thinks her membranes are leaking. She states that some clear fluid has run down her leg. What is the best response from the nurse? A: "You may have just passed some urine. If it were amniotic fluid, there would have been a larger amount." B: "It is best for you to visit the hospital immediately. They can use a nitrazine strip to determine if it's amniotic fluid." C: "There's nothing to worry about if you passed only a little bit. The membranes will seal back over." D: "Go to the hospital now, because this could be dangerous for the baby."
B: "It is best for you to visit the hospital immediately. They can use a nitrazine strip to determine if it's amniotic fluid."
When premature rupture of the membranes (PROM) occurs and labor does not commence within 24 hours, the patient is usually placed on bed rest with pelvic rest. What is pelvic rest? A: a dry cord B: a situation where nothing is placed in the vagina C: disintegrating vessels D: frequent ultrasound examinations
B: a situation where nothing is placed in the vagina
The nurse identifies a nursing diagnosis of risk for injury related to possible effects of oxytocin therapy. Which action would the nurse perform to ensure a positive outcome for the client? A: start administering tocolytic therapy B: assess contractions using an external monitor C: administer hydration and sedation frequently D: turn down oxytocin therapy by half
B: assess contractions using an external monitor
A client in preterm labor is receiving magnesium sulfate and is responding well. Which finding should the nurse prioritize? A: Elevated blood glucose B: Depressed deep tendon reflexes C: Tachypnea D: Bradycardia
B: depressed deep tendon reflexes possible magnesium toxicity
A nurse sees a pregnant client at the clinic. The client is close to her due date. During the visit the nurse would emphasize that the client get evaluated quickly should her membranes rupture spontaneously based on the understanding of which possibility? A: potential rapid birth of fetus B: increased risk of infection C: potential placenta previa D: increased risk of breech presentation
B: increased risk of infection
A nurse is caring for a client following the administration of an epidural block and is preparing to administer an IV fluid bolus. The client's partner asks about the purpose of the IV fluids. Which of the following is an appropriate response for the nurse to make? A: "It is needed to promote increased urine output" B: "It is needed to counteract respiratory depression" C: "It is needed to counteract hypotension" D: "It is needed to prevent oligohydraminos"
C: "It is needed to counteract hypotension"
A nurse is caring for a client and her partner during the second stage of labor. The client's partner asks the nurse to explain how he will know when crowning occurs. Which of the following responses should the nurse make? A: "The placenta will protrude from the vagina" B: "Your partner will report a decrease in the intensity of contractions" C: "The vaginal area will bulge as the baby's head appears" D: "Your partner will report less rectal pressure"
C: "The vaginal area will bulge as the baby's head appears"
The nurse is providing care to a client in labor. On examination, the nurse determines the fetus is at -1 station. The nurse interprets this finding that the fetus is A: 1 cm above the pubic bone B: 1 cm below the pubic bone C: 1 cm above the ischial spines D: 1 cm below the ischial spines
C: 1 cm above the ischial spines
The nurse is assessing a patient who has given birth within the past hour. The nurse would expect to find the patient's fundus at which location? A: between the umbilicus and the symphysis pubis B: one fingerbreadth below the umbilicus C: at the level of the umbilicus D: 2 cm above the umbilicus
C: At the level of the umbilicus
Which assessment following an amniotomy should be conducted first? A: Cervical dilation B: Bladder distention C: FHR pattern D: Maternal blood pressure
C: FHR pattern
A nurse is caring for a client who is in the first stage of labor and is encouraging the client to void every 2 hours. Which of the following statements should the nurse make? A: "A full bladder increases the risk for fetal trauma" B: "A full bladder increases the risk for bladder infections" C: "A distended bladder will be traumatized by frequent pelvic exams" D: "A distended bladder reduces pelvic space needed for birth"
D: "A distended bladder reduces pelvic space needed for birth"
The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement? A: "I won't be in labor until my baby drops" B: "My contractions will be felts in my abdominal area" C: "My contractions will not be as painful if I walk around." D: "My contractions will increase in duration and intensity."
D: "My contractions will increase in duration and intensity."
A woman is to undergo labor induction. The nurse determines that the woman requires cervical ripening if her Bishop score is: A: 7 B: 9 C: 6 D: 5
D: 5 any score less than 6
A client presents to the birthing center in labor. The client's membranes have just ruptured. Which assessment is the nurse's priority? A: FHR B: fetal position C: maternal comfort level D: signs of infection
A: FHR
A nurse in the labor and delivery unit is completing an admission assessment for a client who is at 39 weeks gestation. The client reports that she has been leaking fluid from her vagina for 2 days. Which of the following conditions is the client at risk for developing? A: cord prolapse B: infection C: postpartum hemorrhage D: hydramnios
B: infection
After teaching a review class to a group of perinatal nurses about various methods for cervical ripening, the nurse determines that the teaching was successful when the group identifies which method as surgical? A: prostaglandin B: breast stimulation C: laminaria D: amniotomy
D: amniotomy
A pregnant woman is receiving misoprostol to ripen her cervix and induce labor. The nurse assesses the woman closely for which effect? A: hypotension B: headache C: blurred vision D: uterine hyperstimulation
D: uterine hyperstimulation
A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have: (Select all that apply) 1.Less pressure on her cervix 2.Increased efficiency of contractions 3.Decreased number of contractions 4.The need for increased maternal blood pressure monitoring 5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord.
3. Decreased number of contractions 5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed uterus increases efficiency of contractions
A nurse is caring for a client who is in labor and observes late deceleration on the electronic fetal monitor. Which of the following is the first action the nurse should take? A: Assist the client into the left-lateral position B: Apply a fetal scalp electrode C: Insert an IV catheter D: Perform a vaginal exam
A: Assist the client into the left-lateral position
A nurse is caring for a client who is at 40 weeks gestation and experiencing contractions every 3 to 5 minutes and becoming stronger. A vaginal exam reveals that the client's cervix is 3 cm dilated, 80% effaced, and -1 station. The client asks for pain medication. Which of the following actions should the nurse take? A: Encourage use of patterned breathing techniques B: Insert and indwelling urinary catheter C: Administer opioid analgesic medication D: Suggest application of cold E: Provide ice chips
A: Encourage use of patterned breathing techniques C: Administer opioid analgesic medication D: Suggest application of cold
A nurse is caring for a client who is in active labor and reports severe back pain. During assessment, the fetus is noted to be in the occiput posterior position. Which of the following maternal positions should the nurse suggest to the client to facilitate normal labor progress? A: Hands and knees B: Lithotomy C: Trendelenburg D: Supine with a rolled tower under one hip
A: Hands and knees
A nurse is caring for a client in the third stage of labor. Which of the following findings indicate that placental separation? (Select all that apply) A: Lengthening of the umbilical cord B: Swift gush of clear amniotic fluid C: Softening of the lower uterine segment D: Appearance of dark blood from the vagina E: Fundus firm upon palpation
A: Lengthening of the umbilical cord D: Appearance of dark blood from the vagina E: Fundus firm upon palpation
A nurse is providing care for a client who is in active labor. Her cervix is 5 cm dilated, and her membranes are intact. Based on the use of external electronic fetal monitoring, the nurse notes a FHR of 115 to 125/min with occasional increases up to 150-155/min that last for 25 seconds, and have beat-to-beat variability of 20/minute. There is no slowing of FHR from the baseline. The nurse should recognize that this client is exhibiting signs of which of the following? (select all that apply) A: Moderate variability B: FHR accelerations C: FHR decelerations D: Normal baseline FHR E: Fetal tachycardia
A: Moderate variability B: FHR accelerations D: Normal baseline FHR
The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes for 45 seconds. The nurse notes that the FHR between contractions is 100 bpm. Which nursing action is most appropriate? A: Notify the HCP B: Continuing monitoring FHR C: Encourage the client to continue pushing with each contraction D: Instruct the client's coach to continue to encourage breathing techniques
A: Notify the HCP
A nurse is caring for a client who is at 42 weeks gestation and is admitted to the labor and delivery unit. During an ultrasound, it is noted that the fetus is large for gestational age. The nurse reviews the prescription from the provider to begin an amniofusion. Which of the following conditions should the nurse plan to prepare an amniofusion? (Select all that apply) A: Oligohydramnios B: Hydramnios C: Fetal cord compression D: Hydration E: Fetal immaturity
A: Oligohydraminos C: Fetal cord compression A because inadequate amniotic fluid can contribute to intrauterine growth restriction of the fetus, restrict fetal movement, and cause fetal distress during labor C because A can cause it
The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? A: Provide pain relief measures B: Prepare the client for an amniotomy C: Promote ambulation every 30 minutes D: Monitor the oxytocin infusion closely
A: Provide pain relief measures hypertonic uterine contractions are painful, occur frequently, and are uncoordinated pain relief promotes a normal labor pattern
A nurse is caring for a client who is in the second stage of labor. he client's labor has been progressing, and she is expected to deliver vaginally in 20 minutes, The provider is preparing to administer lidocaine for pain relief and perform an episiotomy. The nurse should know that which of the following types of regional anesthetic block is to be administered? A: Pudendal B: Epidural C: Spinal D: Paracervical
A: Pudendal
A woman is going to have labor induced with oxytocin. Which statement reflects the induction technique the nurse anticipates the primary care provider will order? A: Administer oxytocin diluted as a "piggyback" infusion B: administer oxytocin in a 20 cc bolus of saline C: administer oxytocin diluted in the main intravenous fluid D: administer oxytocin in two divided IM sites
A: administer oxytocin diluted as a "piggyback" infusion
The nurse is caring for a client who is considered low-risk and in active labor. During the second stage, the nurse would evaluate the client's FHR at which frequency? A: every 15 minutes B: every 10 minutes C: every 5 minutes D: every 20 minutes
A: every 15 minutes
A nurse in the labor and delivery unit is caring for a patient in labor and applies an external fetal monitor and tocotransducer. The FHR is around 140/min. Contractions are occurring every 8 minutes and 30-40 seconds in duration. The nurse performs a vaginal exam and finds the cervix 2 cm dilated, 50% effaced, and the fetus at a -2 station. which of the following stages and phases of labor is this client experiencing? A: first stage, latent phase B: first stage, active phase C: first stage, transition phase D: second stage of labor
A: first stage, latent phase
Massage is an effecting nonpharmacological technique that can help to decrease pain during labor. The nurse explains that massage achieves its effect by which mechanism? A: increasing the release of endorphins B: preventing sensation from reaching the brain C: causing vasoconstriction D: distracting the person from the pain
A: increasing the release of endorphins
After conducting a review class on the labor and birth process for a group of nurses working in the community clinic, the nurse determines that the teaching was successful when the group identifies which factors as affecting the labor process? Select all that apply. A: powers B: patience C: passenger D: place E: participation
A: powers B: patience C: passenger
A woman having contractions comes to the emergency room. She tells the nurse that she is at 34 weeks gestation. The nurse examines her and finds that she is already effaced and dilated 2 cm. What is the woman demonstrating? A: preterm labor B: dystocia C: normal labor D: macromasia
A: preterm labor
Hypertonic labor is labor that is characterized by short, irregular contractions without complete relaxation of the uterine wall in between contractions. Hypertonic labor can be caused by an increased sensitivity to oxytocin. What would the nurse do for a client who is in hypertonic labor because of oxytocin augmentation? A: turn off the oxytocin B: turn off the methotrexate C: increase the methotrexate D: increase the oxytocin
A: turn off the oxytocin
The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? A: Identify the types of acclerations B: Assess the baseline fetal heart rate C: Determine the intensity of the contractions D: Determine the frequency of the contractions
B: Assess the baseline fetal heart rate
An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for: 1.Complete bed rest for the remainder of the pregnancy 2.Delivery of the fetus 3.Strict monitoring of intake and output 4.The need for weekly monitoring of coagulation studies until the time of delivery
B: Delivery of the fetus
The nurse is assisting a client undergoing induction of labor at 41 weeks gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal FHR monitor is in place. The baseline FHR has been 120-122 bpm for the past hour. What is the priority nursing action? A: Notify the HCP B: Discontinue the infusion of oxytocin C: Place oxygen on at 8-10 L/minute via face mask D: Contact the client's primary support person(s) if not currently present
B: Discontinue the infusion of oxytocin
A nurse is caring for a patient who is receiving oxytocin for induction of labor and has an intrauterine pressure catheter (IUPC) placed to monitor uterine contractions. For which of the following contraction patterns should the nurse discontinue the infusion of oxytocin? A: Frequency of every 2 minutes B: Duration of 90-120 seconds C: Intensity of 60 to 90 mm Hg D: Resting tone of 15 mm Hg
B: Duration of 90-120 seconds (Hyperstimulation)
The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contract the HCP? A: Hgb of 11 g/dL B: FHR of 180 beats/minute C: Maternal pulse rate of 85 bpm D: WBC count of 12,000 . mm
B: FHR of 180 bpm normal FHR is 110-160 bpm
The nurse is in the postpartum unit caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa? A: Infection B: Hemorrhage C: Chronic hypertension D: Disseminated intravascular coagulation
B: Hemorrhage
The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? A: Providing comfort measures B: Monitoring the FHR C: Changing the patient's position frequently D: Keeping the significant other informed of the progress frequently
B: Monitor the FHR
The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the HCP's prescriptions and should question which prescription? A: Prepare the client for an ultrasound B: Obtain equipment for a manual pelvic exam C: Prepare to draw a hgb and hct blood sample D: Obtain equipment for external electronic FHR monitoring
B: Obtain equipment for a manual pelvic exam
A nurse is performing Leopold maneuvers on a client who is in labor. Which of the following techniques should the nurse use to identify the fetal lie? A: Apply palms of both hands to sides of uterus. B: Palpate the fundus of the uterus C: Grasp lower uterine segment between thumb and fingers D: Stand facing client's feet with fingertips outlining cephalic prominence
B: Palpate the fundus of the uterus identifies the fetal part that is present
A nurse is caring for a client who is in the transition phase of labor and reports that she needs to have a bowel movement with the peak of contractions. Which of the following actions should the nurse make? A: Assist the client to the bathroom B: Prepare for an impending delivery C: Prepare to remove a fecal impaction D: Encourage the client to take deep, cleansing breaths
B: Prepare for an impending delivery
A nurse is caring for a client who is in labor and experiencing incomplete uterine relaxation between hypertonic contractions. The nurse should identify that this contraction pattern increases the risk for which of the following complications? A: Prolonged labor B: Reduced fetal oxygen supply C: Delayed cervical dilation D: Increased maternal stress
B: Reduced fetal oxygen supply
The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? A: Ambulation B: Rest between contractions C: Change positions frequently D: Consume oral food and fluids
B: Rest between contractions
A nurse is caring for a client who is in active labor. The client reports lower-back pain. The nurse suspects that this pain is related to a persistent occiput posterior fetal position. Which of the following nonpharmacological interventions should the nurse recommend to the client? A: Abdominal effleurage B: Sacral counterpressure C: Showering if not contraindicated D: Back rub and massage
B: Sacral counterpressure
The nurse is performing an assessment on a client who has just been told that a pregnancy test is positive. Which assessment finding indicates that the patient is at risk for PTL? A: 35-year-old primagravada B: The client has a history of cardiac disease C: Hgb level is 13.5 D: 20 year old primigravada of average weight and height
B: The client has a history of cardiac disease
The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present? A: Soft abdomen B: Uterine tenderness C: Absence of abdominal pain D: Painless, bright red vaginal bleeding
B: Uterine tenderness
A client experiences a large hush of fluid from her vagina while walking in the hallway of a birthing unit. Which of the following actions should the nurse take first? A: check the amniotic fluid for meconium B: monitor FHR for distress C: dry the client and make her comfortable D: monitor uterine contractions
B: monitor for fetal distress this checks for umbilical cord prolapse
During the examination, the health care provider mentions the fetus has a good attitude. The nurse explains to the parents that this means: A: the posture of the fetus is with arms at its sides and legs straight B: the posture of the fetus is with all joints flexed for birth C: the fetus is presenting head first D: the fetus is cooperating with the labor
B: the posture of the fetus is with all joints flexed for birth
A nurse is caring for a client who is at 42 weeks of gestation and in active labor. Which of the following findings is the fetus at risk for developing? A: Intrauterine growth restriction B: Hyperglycemia C: Meconium aspiration D: Polyhydraminos
C: Meconium aspiration
The nurse is reviewing the HCP's prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is 37 weeks. Which prescription should the nurse question? A: Monitor FHR continuously B: Monitor maternal vital signs frequently C: Perform a vaginal exam every shift D: Administer an antibiotic per HCP prescription and per agency protocol
C: Perform a vaginal exam every shift Do not want to do frequently because of risk for infection
A nurse is caring for a client who had no prenatal care, is Rh- negative, and will undergo an external version at 37 weeks of gestation. Which of the following medications should the nurse plan to administer prior to the version? A: Prostaglandin gel B: Magnesium sulfate C: Rho(D) immune globulin D: Oxytocin
C: Rho(D) immune globulin
The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. A: The contractions are regular B: The membranes have ruptured C: The cervix is dilated completely D: The client begins to expel clear vaginal fluid E: The spontaneous urge to push is initiated from perineal pressure
C: The cervix is dilated completely E: The spontaneous urge to push is initiated from perineal pressure
After an hour of oxytocin therapy, a woman in labor states she feels dizzy and nauseated. Your best action would be to a) administer oral orange juice for added potassium. b) assess her vaginally for full dilation. c) assess the rate of flow of the oxytocin infusion. d) instruct her to breathe in and out rapidly.
C: assess the rate of flow of the oxytocin infusion
A nurse is caring for a woman in labor. The woman's membranes just ruptured. The nurse assesses the characteristics of the fluid. Which finding would the nurse identify as normal? A: cloudy B: malodorous C: clear D: green
C: clear
A woman is in the fourth stage of labor. During the first hour of this stage, the nurse would assess the woman's fundus at which frequency? A: every 5 minutes B: every 10 minutes C: every 15 minutes D: every 20 minutes
C: every 15 minutes
A client calls the clinic asking coming in to be evaluated. She states that when she went to bed last night the fetus was high in the abdomen, but this morning the fetus feels like it has dropped down. After asking several questions, the nurses explains this is due to: A: start of labor B: placenta previa C: lightening D: rupture of the membrane
C: lightening
A nursing student working with a client in preterm labor correctly identifies which medication as being used to relax the smooth muscles of the uterus and for seizure prophylaxis and treatment in clients with preeclampsia? A: nifedipine B: indomethacin C: magnesium sulfate D: bethamethasone
C: magnesium sulfate
A woman in labor for over 12 hours has very little progress. The HCP thinks that her contractions lack the force needed to propel the infant downward into the birth canal. The provider asks the group of students which hormone may be given to increase the force of the contraction. Which hormone would be best? A: ADH B: LH C: oxytocin D: GH
C: oxytocin
A nurse is explaining to a pregnant client about the changes occurring in the body in preparation of labor. Which hormone would the nurse include in the explanation as being responsible for causing pelvic connective tissue to become more relaxed and elastic? A: prolactin B: oxytocin C: relaxin D: progesterone
C: relaxin
A 19-year-old presents in advanced labor. Examination reveals the fetus is in frank breech position. The nurse interprets this finding as indicating: A: one arm is presenting B: the fetus is sitting cross-legged above the cervix C: the buttocks are presenting first with both legs extended up towards the face D: one leg is presenting
C: the buttocks are presenting first with both legs extended up towards the face
On examination, the nurse determines the client is at 50% effacement. This means: A: the cervical canal is 1.5 cm long B: the cervical canal is 2 cm long C: the cervical canal is 1 cm long D: the cervical canal is 2.5 cm long
C: the cervical canal is 1 cm long
A nurse is caring for a client who is in active labor and becomes nauseous and vomits. The client is very irritable and feels the urge to have a bowel movement. She states, "I've had enough. I can't do this anymore. I want to go home right now." Which of the following stages of labor is the client in? A: first B: fourth C: transition D: latent
C: transition
Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what is the most important nursing action? A: Slow the IV flow rate B: Continue the oxytocin rate if infusing C: Place the client in a high Fowler's position D: Administer O2, 8-10 L/min, via face mask
D: Administer O2, 8-10 L/min, via face mask
The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply. A: Uterine rigidity B: Uterine tenderness C: Severe abdominal pain D: Bright red vaginal bleeding E: Soft, relaxed, nontender uterus F: Fundal height may be greater than expected for gestational age
D: Bright red vaginal bleeding E: Soft, relaxed, nontender uterus F: Fundal height may be greater than expected for gestational age
A nurse is caring for a client in active labor. When last examined 2 hours ago, the client's cervix was 3 cm dilated, 100% effaced, membranes intact, and the fetus was at a -2 station. The client suddenly states "My water broke". The monitor reveals a FHR of 80 to 85/min, and the nurse performs a vaginal examination, noticing clear fluid and a pulsing loop of umbilical cord in the client's vagina. Which of the following actions should the nurse perform first? A: Place the client in the Trendelenburg postion B: Apply pressure o the presenting part with her fingers C: Administer oxygen at 10L/min via a face mask D: Call for assistance
D: Call for assistance
A nurse in labor and delivery is planning care for a newly admitted client who reports she is in labor and has been having vaginal bleeding for 2 weeks. Which of the following should the nurse include in the plan of care? A. Inspect the introitus for a prolapsed cord. B. Perform a test to identify the ferning pattern. C. Monitor station of the presenting part. D. Defer vaginal examinations.
D: Defer vaginal examinations not performed until placenta previa or abruptio placentae have been ruled out
The nurse is caring for a client in labor and is monitoring the FHR patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitoring tracing. Which actions is most appropriate? A: Notify the HCP B: Reposition the mother and check the monitor for changes in the fetal tracing C: Take the mother's vital signs and tell the mother that bed rest is required to conserve oxygen D: Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being
D: Document the findings and tell the mother that the pattern on the monitor indicates fetal well-being
The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise? A: Maternal fatigue B: Coordinated uterine contractions C: Progressive changes in the cervix D: Persistent nonreassuring fetal heart rate
D: Persistent nonreassuring FHR
A nurse is caring for a client who is using patterned breathing during labor. The client reports numbness and tingling of the fingers. WHich of the following actions should the nurse take? A: Administer oxygen via nasal cannula 2L/min B: Apply a warm blanket C: Assist the client into a side-lying position D: Place an oxygen mask over the client's mouth and nose
D: Place an oxygen mask over the client's mouth and nose this is due to the client experiencing hyperventilation caused by low serum levels of CO2
A nurse is caring for a client who is admitted o the labor and delivery unit. With the use of Leopold maneuvers, it is noted that the fetus is in a breech presentation. For which of the following possible complications should the nurse observe? A: Precipitous labor B: Premature rupture of membranes C: Postmaturity syndrome D: Prolapsed umbilical cord
D: Prolapsed umbilical cord
A nurse is reviewing the electronic monitor tracing of a client who is in active labor. The nurse should know that a fetus receives more oxygen when which of the following appears on the tracing? A: Peak of the uterine contraction B: Moderate variability C: FHR acceleration D: Relaxation between uterine contractions
D: Relaxation between uterine contractions
A woman who has had preterm labor and PROM successfully halted has reached 36 weeks and is doing well at home. Which of the following nursing diagnoses should the nurse prioritize for the client? A: Powerlessness related to inability to sustain this pregnancy B: Anticipatory grieving related to high probability of fetal demise C: Hopelessness related to potential loss of pregnancy D: Risk of fetal infection related to early rupture of membranes
D: Risk of fetal infection related to early rupture of membranes
The nurse is reviewing the uterine contraction pattern and identifies the peak intensity, documenting this phase as what of the contraction? A: increment B: diastole C: decrement D: acme
D: acme
A nurse assesses a client in labor and suspects hypotonic uterine dysfunction. Which intervention would the nurse expect to include in the plan of care for this client? A: providing a comfortable environment with dim lighting B: preparing the woman for an amniotomy C: encouraging the woman to assume a hands-and-knees position D: administering oxytocin
D: administering oxytocin
Which neonatal assessment is the highest priority if the mother received meperidine during labor? A: time of the first meconium B: lung sounds C: temperature regulation D: respiratory rate
D: respiratory rate
A young woman experiencing contractions arrives at the emergency department. After examining her, the nurse learns that the client is 33 weeks gestation. What treatment can the nurse expect to be prescribed? A: muscle relaxants B: bronchodilators C: anti-anxiety therapy D: tocolytic therapy
D: tocolytic therapy given before 34 weeks in order to prevent labor progression or stop it
A nurse in the L and D unit receives a phone call from a client who reports that her contractions started about 2 hours ago, did not go away when she had two glasses of water, and rested, and became stronger since she started walking. her contractions occur every 10 minutes and last about 30 seconds. She hasn't had any fluid leak from her vagina. However, she saw some blood when she wiped after avoiding. Based on this report, which of the following clinical findings should the nurse recognize that the client is experiencing? A: Braxton Hicks contractions B: rupture of membranes C: fetal descent D: true contractions
D: true contractions true contractions don't go away with hydration or walking they are regular in frequency, duration, and intensity, and become stronger with walking
A pregnant client undergoing labor induction is receiving an oxytocin infusion. Which finding would require immediate attention? A: contractions every 2 minutes, lasting 45 seconds B: uterine resting tone of 14 mm Hg C: fetal heart rate of 150 beats per minute D: urine output of 20 ml/hour
D: urine output of 20 ml/hour oxytocin can cause water intoxication
